- Independent mental health service
Thornford Park
Assessment report published 15 September 2025
Contents
Ratings - Forensic inpatient or secure wards
Our view of the service
During this assessment, we found that:
There were a number of significant environmental safety issues that the provider needed to address including a leaking roof in one of the wards, damaged walls and ceilings, as well as lack of a dedicated entrance to Headley ward in line with the Health Building Notes 03-01 Supplement 1: Medium and low secure mental health facilities for adults. While the provider informed us that there was a capital bid in place, and there were some ongoing repairs to address these issues, we were concerned that patients could be at risk. This was a breach of Regulation 15, Premises and equipment.
The provider did not take all practicable steps to ensure that care and treatment provided to patients was consistently appropriate, met their needs and reflected their preferences. More than half of patients we spoke with said they either did not have a care plan, or they were not involved in developing their care plan. Staff did not always ensure the areas used for long-term segregation were kept clean. The environment was dirty and littered with take away boxes and left over food. The ensuite bathroom in the seclusion room was very dirty. This was a breach of Regulation 9 Person Centred Care.
Ward managers completed environmental and ligature audits with the estates manager. While most of the potential ligature points were identified with actions to mitigate the risks, we identified areas on the wards that were potential fixed ligature anchor points and blind spots, including on Bucklebury, Headley and Oakley wards. Managers told us that there was no specific training for how to complete ligature risk assessments.
The roof on some wards was easily accessible through the garden. The rear garden fence on Headley ward was easily scalable and this was not included on the provider’s risk register. Although, staff told us if a person was at risk of absconding, that area would be on enhanced monitoring by staff.
The wards were not always cleaned to a high standard. Patients we spoke with said that the wards could be cleaner. We saw that areas were littered with food and the ensuite bathrooms were dirty. The walls were stained on Bucklebury and there were watermarks on the ceiling. This was a breach of Regulation 12: Safe Care and Treatment.
Patients reported that the wards were very loud and uncomfortable because of the emergency alarms going off on other wards. While some wards had quiet rooms, during our assessment we observed, for example, Bucklebury ward was very noisy with alarms sounding for long periods of time and lights flashing on the ward outside of bedrooms even though the alarm was activated on another ward in the hospital.
Patients across 5 wards including Adbury, Donnington, Bucklebury, Kingsclere and Headley said that staff did not always treat them kindly or behave appropriately towards them.
Patients told us that when staff did nighttime observation, the rays from the torches usually woke them up. In addition, some patients reported that they did not always have one to one time with their named nurse. This was a breach of regulation 10: Dignity and respect.
Patients told us that the food was not always of good quality, tasteful and of good portion sizes. Some patients said that the food was not always fresh. Patients said that there were not always vegetarian options. Patients reported that the food was not always tasteful, and the portion sizes were small and not filling. Patients said they often get takeaways to meet their dietary needs. This was a breach of regulation 14: Meeting nutritional and hydration needs.
Staff did not always ensure that patients had a care plan that was developed collaboratively with them. Care plans were not always holistic and personalised. In addition, staff did not always ensure that there were clear plans to manage and support patients with additional care needs such as managing their hygiene or physical health condition.
Staff did not ensure that information was always readily available that met the Accessible Information Standard such as easy read for patients in the learning disability and autism wards.This was a breach of regulation 9: Person-centred care
The provider’s governance systems and processes were not robust enough to mitigate risks. There was significant remedial work required to make the ward environments safe and fit for purpose. For example, there were damaged walls with the plaster coming off, a leaking roof, and a lack of dedicated access to some wards with no clear timeframes when these issues will be addressed.
Staff had not realised that they could always access the firefighting equipment on some wards, and the environmental risk and security audit had not identified this issue.This was a breach of regulation 17: Good governance.
However,
There was a robust process around complaints and incident management. Patients we spoke with said they knew how to make a complaint, and staff supported them to do so. Patients received feedback on complaints and there was learning from incidents to improve the service.
Staff completed a comprehensive risk assessment for patients on admission and regularly reviewed risks.
There was a clear pathway for patients in line with the model of care for forensic services. Patients had a discharge plan or moving on plans to ensure that discharges were successful.
The service had an effective multidisciplinary team including doctors, nurses, allied health professionals and support staff who worked well together.
The hospital director had a clear vision for what they wanted to achieve at the service and was developing and implementing systems and processes focussed on supporting staff wellbeing and ensuring everyone promoted a culture of safe, good quality, person centred care and treatment. All staff spoken with were positive about the new leadership team and said they had made a significant impact and positive change. The leadership team were working towards addressing the concerns we raised following the assessment, and when we made another unannounced visit to the service on 13th March 2025, we saw that there was work in progress to fix the leaking roof.
Staff said that they would recommend Thornford park as a good place to work. Staff felt there were opportunities for growth and career development. Leaders actively encouraged innovation, and the teams were working to improve outcomes for patients.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
There was mixed feedback from patients about how staff cared for them. While some patients said they felt safe on the wards, and that their experiences of discrimination and inequality were listened to and acted on to improve care, some patients reported staff did not always meet their needs. For example, patients said staff did not always work collaboratively with them to create a care plan that met their holistic needs. They said there were activities on the wards including art and drama therapy, but these were not always relevant to them. Patients reported there were limited opportunities for work and education. The provider informed us this was now being reintroduced, and some patients were being supported with their Maths and English qualifications.
Over 50% of patients said that the food did not meet their needs. Patients raised concerns about the portion sizes, taste, and quality of the food. Patients said they often had takeaway to meet their dietary needs.
Patients reported that the environment was very noisy, mostly due to the continuous sounding of emergency alarms on other wards, which made it difficult to relax. They also told us the wards were often too busy with staff passing through the wards to get to other areas of the hospital.
However, patients felt they could give feedback on their care and the provider encouraged them to do so. They told us they knew how to find information about advocacy and could speak to them about their care and treatment. They felt empowered by the provider and staff to give their views and understand their rights, including their rights to equality and their human rights.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice. Patients had easy access to information about independent mental health advocacy.
Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.
Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.
The service displayed a notice to tell informal patients that they could leave the ward freely.
Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment.
Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.
Mental Capacity Act
The provider did not ensure there were clear records of how they complied with the Mental Capacity Act. While the provider had policy and a form to record how staff applied the Mental Capacity Act, at the time of the inspection, the provider could not evidence that this was being monitored appropriately. We reviewed clinical governance meeting minutes for January, February and March 2025 and observed that there were no discussions around the Mental Capacity Act or their compliance with the Act.
However, staff had had training in the Mental Capacity Act. They had a good understanding of the Mental Capacity Act and were able to explain the five statutory principles. The provider informed us that they monitored the Deprivation of Liberty Safeguards applications (DoLS). The provider had not made any DoLS application in the last 12 months.